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What I Wanted vs. What We’re Getting

Ostrich alert: The following post deals with healthcare reform. Skip it if you don’t want my opinion on this depressing topic.

Back in July, a bunch of medbloggers went to Washington DC for a Health Care Reform: Putting Patients First panel. When (prior to the trip), people pointed out the irony of politicians and physicians claiming to put patients first without asking patients what they want, Dr. Rob openly invited input. Here’s my wish list, which I originally posted as a comment on Dr. Rob’s Speak To Me post:

Retain Insurance
I want to be able to keep my insurance at a reasonable price. I don’t want to be forced onto a different plan (or dropped) when the insurance company stops making money off of me.

Real Coverage
For the most part, my insurance is good. However, some things are covered only in theory, not in reality. Example: according to my plan booklet, speech therapy is covered. Since many speech issues are developmental, therapists often recommend waiting until children reach age seven or eight to see if they outgrow the problem. I waited. And waited. Finally, our doctor wrote a referral. And I learned that there’s more to it than the plan book we received, and that the fine print (in a file in some obscure closet) says “only until age six.” This means that speech therapy for children is not really covered. At all. Insurers can write whatever they want in a policy, but they shouldn’t be able to claim they’re offering coverage for something when they really aren’t.

Malpractice Reform
I want my doctor to be free to do what is best without having the threat of a frivolous malpractice suit hanging over his head. If premiums for malpractice insurance weren’t so high, doctors would have more take-home pay without having to generate more income. When there is a physician shortage, obstacles such as this need to be addressed.

Fair Pay
I like my doctor, and I don’t want him to retire early or take a different job because he can’t make ends meet. I’d like my doctor to be fairly compensated for his services so that he stays in practice as long as possible.

Most service providers (the electrician, the plumber, the housekeeper, the babysitter, the tutor) are paid an hourly rate for their labor. It is in their best interests to take the time to do my job right. Whether the job takes thirty minutes or two hours, they take as much time as is needed to get the job done, and bill accordingly. Another example is the legal profession. Attorneys bill by the hour – not just time spent with a client, but also for time spent working on behalf of a client.

Medical services are the exception, and medical services suffer as a result. Doctors do not get paid for their time, but for the number of people they can see. Sometimes a simple medical issue could be thoroughly addressed in twenty minutes instead of fifteen, but doctors only get paid for it if they bring patients back for a second appointment rather than take the extra time to take care of the problem in a single office visit. By paying doctors for their time, they would be freed from the tyranny of running patients through exam rooms as if they were working on an assembly line. Patients would benefit by getting the time they really need, without the inconvenience of a second appointment.

Fair pay would include compensating doctors for time spent on behalf of a patient, for things such as writing referrals, determining a treatment plan for complicated conditions, phone calls/emails, or jumping through insurance hoops for preapproval. If insurance companies knew they’d be billed for the amount of time it took the doctor to deal with them, would they respond differently?

I realize that this topic typically comes from doctors, but it comes from patients, too. “You get what you pay for.” I am accustomed to paying for high quality work, firing people who provide poor service, and giving a bonus for a job well done. Yet when I read the EOB’s from my insurance company, I wonder how doctors can afford to run a practice on the reimbursement they receive.

Confidentiality
I want what transpires between me and my doctor to be confidential. It is not. The solution is not additional regulation, nor is it threat of punishment/fines for violations. The solution is to permit doctors to maintain confidentiality. Doctors are required to provide information to insurers, and insurers have demonstrated an appalling propensity for releasing medical information to employers. The system needs to be fixed so that doctors can be paid without releasing a diagnosis code (or any other information).

A Level Playing Field
I have no confidence that the politicians will do what is best for anyone, unless they have some skin in the game. “Separate but equal” doesn’t exist in civil rights, and it won’t exist in the healthcare world. Our senators, representatives, and president need to have the same plan that the rest of the country gets.

Respect Good Doctors
Give my doctor the freedom to do his job. I want my doctor to use his expertise to diagnose and treat me. My doctor should be able to order tests based on his medical judgment of what is needed, not based on the pre-approval of an outside source. I want a treatment plan based on what is most appropriate for my specific situation, not based on some cookie-cutter recommendations developed for the “average” patient.

Responsible Use of My Tax Dollar
Healthcare reform should include having a team of ER doctors rewrite the emergency access law. Why do I include this in what patients want? Because when my two-year-old falls on a big piece of metal and cuts a three-inch gash across his forehead, I don’t want to wait while the emergency doctor writes a non-emergency prescription for a Medicaid mom to get her kid some children’s Tylenol. The people who are most affected by the problems of the current law would have good ideas on how to fix it.

I am willing to contribute taxes toward the healthcare of people who fall sick due to misfortune. I don’t want tax dollars to pay for treating people if they willfully make lifestyle choices that cause their own poor health. Someone who can find money for cigarettes can find money for their own lung cancer treatments. People who have been able to purchase enough food to weigh 400 pounds (not caused by a medical condition) can come up with their own money for insulin, heart medication, knee replacements, etc. I know doctors aren’t supposed to judge patients, but other patients do it all the time. Tell the politicians that making people live with the consequences of their actions will help keep costs down.

Affordable Meds
I want medication to be affordable. Actually, what I really want is a cure. Until a cure is discovered, I’ll make do with meds. My concern is that healthcare reform, done wrong, can result in companies being unwilling to develop new treatments. Pharmaceutical companies (like all businesses) need to earn a profit. Look at biologic response modifiers. Biosimilars (generic biologics) sound like a great idea to the person paying for these expensive drugs, but if the pharmaceutical companies decide there isn’t enough profit in these, we all lose. Reform needs to encourage research and the development of new treatments.

So how’d Congress do last night?

Effective 2014, insurers won’t be able to deny coverage based on pre-existing conditions. Rates charged are a whole ‘nother thing.

No.

Nope.

Didn’t happen.

This didn’t change either.

You’ve got to be kidding!

Don’t see this addressed.

Not even considered.

Sigh

I predict that we’ll see more emergency rooms close, more doctors drop medicare/tricare, and people have a harder time finding a doctor. But at least everyone will be able to say that they have insurance.

Um, it’s worth noting that weight is not a simple calories in/calories out model. If it was, we really wouldn’t see as many overweight people as we do.

In the short term, yes, you can short yourself calories or add exercise to lose weight. Over 2 years, even if that plan is maintained, the body moves back to ‘set-point’.

It’s theoretically possible to alter one’s set point. The most effective way of making your set point higher that we know of is crash dieting. There’s a reason for the phenomenon of someone losing a ton of weight and gaining it all back plus some. We don’t know of effective ways to lower your set point, though.

There are a few things we know of that may contribute to weight gain (other than the calories in/calories out standard which is bunk – I suggest you read http://mann.bol.ucla.edu/files/Diets_don't_work.pdf for example). There has been more than a few suggestions that high fructose corn syrup messes with the body’s insulin and causes weight gain. I’ve read that eating only one meal a day – which a lot of people do, because that’s all they can squeeze in around work – is harmful. We know some medications cause weight gain.

Also, if you’re going to suggest that calorie reduction is a healthy thing, I suggest you investigate the Minnesota Starvation Study, done in the ’40s.

Okay, Kali, I give up. Did you post this on the wrong blog? I don’t think I’ve written about dieting/weight loss. Not that I haven’t considered it – I just don’t recall doing it yet. Your comment has nothing to do with my post – but it just might motivate me to write about weight one of these days.

Nope, it was a response to this line – “People who have been able to purchase enough food to weigh 400 pounds (not caused by a medical condition) can come up with their own money for insulin, heart medication, knee replacements, etc.”

I should clarify what I just said. By saying that people get to that weight by buying lots of food, you imply that it’s a calories in/calories out model. Buying (and by implication, eating) a lot of food = getting fat.